34 CALUMET ST - BPA-15-566 The Commonwealth of Massachuse
Board of Building Regulations�,,�[O,�Wlit S CITY OF
y�e�w, N10E SALEM
Massachusetts State B dd CCp�V�p0
�5� Revised Mar 2011
Building Permit Application To Construct,Repair,RenotVe'gr3i3molish a
Fa One-or Two- y}� Y''
This Section For Official Use Only
Building Permit Number: Date Applied:
c� tt
Building Official(Print Name) SignaturiA WJ Date
SECTION 1:SITE INFORMATION
rDistrict
Address: 1.2 Assessors Map&Parcel Numbers
� N�� ��accepted street?yes nt/ o Map Number Parcel Number
formation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: tl-.:8ewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone? i
Check if yes[] pal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'�qfReirl f:tAHE ty 54GcH
AND X rco _ CYZs/lln f' ! ,
Name(Print) City,State,ZIP
3 N Cj4b(A 1M CT' ST
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repatrs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed World: s' r Y b o a4(L I Ce iA 0 t.cl
1 ✓1 �4AtC qfr�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ indicate bow fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier_�C
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: �S
5.Mechanical (Fire $
Su ression Total All Fees:$
�J Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ is y b ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.11 Construction Supervisor License(CSL)
l� /��r�� 3 (L,
CS O�O /t7D d 6 2a�S
o t4— /�} , (L, License Number Expiation ate
Name of CSL Holder
.L y . List CSL Type(see below)
7
No.and Street Type Description
/1 J C _ L, �� D 2/ t f 9 U Unrestricted(Buildings u to 35,000 cu.ft.
k Cam! 7 / R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
p SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
M141/,eD � CDh S �NCf Io✓1 / O 6
/ e MC Registration Number xpvahon Date
I L ompapy I]am�e�O CAR,istra�tNa e /
7S !lrr--6)y ,/- �i pt�/ R J r o t' P(1)PO 60.CNP,and '1''
YeA E7eet r) 7 �l d�96/0 ? �r ?H yg/3 Email address
City/Town, Stat ,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7bt OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and acc tra est of my knowledge and understand7/
n
�Pa tNA (,o /i 20 f S
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.a 142A.Other important information on the HIC Program can be found at
wvnv.mass.gov,'oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"